Feb 2006, compiled few cogent first
aid articles, linked to each other.

38 pages

6 Pages

44
pages

7 Pages

4 pages

Version 2.00
Created September 1997
Supersedes Version 1.00

Medical FAQ By Craig Ellis

Excluding contributions attributed to specific individuals, all material is
copyrighted to the author and all rights are reserved. This work may be copied
and distributed freely as long as the entire text and all disclaimers and
copyright notices remain intact, unless my prior permission is obtained. This
FAQ may not be distributed for financial gain, included in any commercial
collections or compilations or included as any part of a wed site without the
permission of the author.

(Copyright.(c) Craig Ellis 1997)

Thanks to Richard DeCastro, Diana and Alan Hagan and Pat Turner for comments
and suggestions.

All views in this FAQ reflect only my opinions and is not to be considered in
any way a professional opinion or advice.

Any constructive comments and debate are welcome. I welcome correction in any
errors of fact. I apologise for any errors of grammar or spelling they are
entirely mine. I've tried to avoid detailing specific managements for various
conditions as I do not consider this to be an appropriate forum. I will,
however, respond to specific questions, with suitable references on request.

[Alan's note: Craig is in New Zealand and many of his words use the British
spelling.]

Disclaimer: The author accepts no responsibility for the use or misuse of
this information. The practice of medicine is something that should only be
practiced by trained professionals. If you start administering medical or
surgical treatments without the appropriate skills you will kill someone. Even
in emergency situations, often no action is better than uninformed and untrained
action. Any practice of survival medicine should be backed up with appropriate
training. This information is offered as my personal opinion and should not be
taken to represent a professional opinion or to reflect any views widely held
from the medical community.

What is survival medicine? My definition is: "the practice of medicine in
a environment or situation where standard medical care and facilities are
unavailable, often by persons with no formal medical training". This includes
medical care while trekking in third world countries, deep water ocean
sailing, in some cases isolated tramping and trekking in a developed country
and of course post-The End Of The World As We Know It (TEOTWAWKI).

The basic assumption is that trained doctors and hospital care will be
unavailable for a prolonged period of time and that in addition to providing
first aid, definitive medical care and rehabilitation (if required) will need
to be provided. Also the basics of personal and public hygiene will also need
to be considered.

As is the case with any aspect of preparedness you need to decide what you
are preparing for and plan accordingly. For some it will only be a 72 hr
crisis; For others it will be a major long term event. Your medical
preparations will need to reflect your own risk assessments, in terms of what
knowledge and skills you develop and what you store. This FAQ is more slanted
to longer term preparedness, but much is applicable to shorter term
situations.

The more the better. Keep reading and attend all the courses you can. In
addition to an advanced EMT course the following skills are what I feel the
person filling the role of "medic", should aim to be able to do:

The most important aspect of survival medicine is to obtain knowledge and the
skills related to it. Medicine is dangerous and uninformed decisions and actions
will kill people. But, having said that, a lot of medicine is common sense.
Anyone with a bit of intelligence, a good anatomy and physiology book, and a
good medical text can easily learn the basics. Although, I have to stress: There
is no alternative to a trained health care professional; anything else is taking
risks. Obviously in survival situation any informed medical care is better than
no medical care. Notice I said informed, if you really don't have a clue what
you are doing, you will be very dangerous.

3.1 Formal training

Professional medical training:

One option is undertaking college study in a medical area e.g. Medicine,
Nursing, Physicians Assistant, Paramedic, Vet, etc. Obviously this is not an
option for many, but it is the ideal situation.

EMT/Wilderness EMT Course:

The much more realistic option. These courses give an basic background in
anatomy and physiology, medical terminology and the essentials of emergency
medicine. It provides the basis for additional self-directed learning. Most
community colleges offer these courses. The basics are well covered in the
"first responder" courses, which, although very elementary, provide a good
stepping stone to the more advanced courses, while not requiring the same time
commitments as full EMT courses.

3.2 Informal Training

There are a variety of options here. Certainly, locally (New Zealand, and
I realise the US may be different) it is possible to gain some experience in
an ER. In our emergency department we regularly have a variety of people
coming through for practical experience, from army medics, to off-shore island
forest service staff, to fishing boat medics. If you can provide a good reason
for wanting to gain skills in the emergency room such as "sailing your boat to
the South Pacific", then the potential to gain practical experience in
suturing, inserting IV's, and burns management is there. Another option is
befriending (or recruiting) a health care professional and arranging teaching
through them. It is common for doctors to be asked to talk to various groups
on different topics, so an invitation to talk to a "tramping club" about pain
relief or treating a fracture in the bush would not be seen as unusual.

3.3 Volunteering

Many ambulances and fire services have volunteer sections or are
completely run by volunteers. Through these services you may be able to obtain
formal EMT training and at the same time gain valuable practical skills and
experience, overcome fear of dealing with acutely sick people and also work
with some great people. Organisations such as the Red Cross or Search and
Rescue units also offer basic first aid training as well as training in
disaster relief and outdoor skills. It is also often possible to arrange "ride
alongs" with ambulance and paramedic units, as the 3rd person on the crew.

4.1 If you are alone or just a couple then organising your medical care is
relatively straight-forward. However the larger the group the more formalised
and structured your medical care should be. Someone within your group, ideally
with a medical background, should be appointed medic. Their role is to build
up their skill and knowledge base to be able to provide medical care to the
group. There should also be a certain amount of cross-training to ensure that
if the medic is the sick one, there is someone else with some advanced
knowledge. The medic should also be responsible for the development and
rotation of the medical stores and for issues relating to sanitation and
hygiene. In regard to medical matters and hygiene their decisions should be
absolute.

4.2 Another important area is that of confidentiality and trust. This is a
corner stone of any medical relationship. It may seem an odd thing to mention
in regards to a survival situation, but all doctors, nurses, paramedics will
tell you without trust you can't practice. You need to trust that what you
tell your medic will go no further and personal problems won't become
dinner-time conversations. Obviously, this has to be weighed against the
"common good" of the group, but unless it would place the group in danger
there should be an absolute rule of confidentiality.

4.3 Even in a survival situation documentation is important. You should
keep a record of every patient you treat. What they complained of, your
history and examination, what you diagnosed and how you managed them, a very
clear note of any drugs you administer and a description of any surgical
procedure you perform should all be recorded. Anyone with an ongoing problem
should have a chronological record of their condition and treatment over time
recorded.

There are two reasons for this:

First is that for the ongoing care of the patient, often it is only
possible to make a diagnosis by looking over a course of events within
retrospect and it is also important to have a record of objective findings
to compare, to recognise any changes over time in the patient condition.

Second is for legal reasons. If and when things return to normal it may
be important to justify why certain decisions were made. Detailed notes from
the time will make this easier. It is also useful to have medical records on
members of your group prior to any event, including things such as blood
groups and any possible medical problems.

4.4 The persisting survival theme of how you deal with the "have not's"
when they approach you, applies to medicine as much as to food and other
supplies. Obviously complete isolation is one option, but this is unlikely to
be that common. How do you deal with the stranger dumped on you with the
gunshot wound or pneumonia? It's one thing to give them a meal, but do you
give them the last of your IV antibiotics or your one dose of IV anesthetic?
You need to have thought about these things. People can often "live of the
land" and forage for food, but they can not forage for penicillin. Its also
worth realising that these people may be more likely to be in poor general
health and also carriers of infectious diseases. This raises the question of
isolation vs. community involvement again. One possible option may be to
quarantine the refugees for a period before any contact with your group.

Good medical reference books are vital. The following is a list in two
parts. First are books I think are a really solid starting point for a
survival medicine library and then a selection of other useful medical books
with varying strengths and weaknesses. What you prefer is to a great extent
personal opinion. Most can be obtained from any university book shop, Paladin
Press or from Amazon.com. There are titles and authors for all books, but only
ISBN's and approximate prices (US$) for some.

5.1 Must haves:

1) Where There is No Doctor. By Werner. Hesperian Foundation 1992 $20 If
you buy no other medical book, you must have this one. This is the must-have
of survival medicine; it WILL save lives. Although slanted to the third
world (= TEOTW.. environment ?) and the tropics, it contains the essential
basics of all aspects of medicine.

3) An Anatomy and Physiology reference.
* Functional Anatomy and Physiology. By Yamamoto. 1996 $30
* Essentials of Anatomy and Physiology. By Scancon. ISBN 0803677359
* An anatomy atlas such as Grays or Grants are also excellent for any
do-it-yourself surgery. :-)

N.B There are a number of collectors editions of Grays anatomy, you
should avoid these if possible and purchase a new edition.

4) Where There is No Dentist. By Dickson. Hesperian Foundation 1983 $9
The only book of its kind. Very good. Dental care is a very under estimated
survival problem.

5) An emergency medicine reference
* Emergency Care in the Streets. By Caroline. 1995. $50
My choice, but both are good books. Textbooks of paramedic care.
* Mosby's Paramedic Textbook. By Sanders $50

8) A Herbal/Medicinal Plant guide to your area. The basis of most of the
modern drugs is in plants and large numbers have potent medicinal
properties. Also local indigenous peoples often have books about their
traditional medicine. You need to be careful separating out what's useful
and what's not, but it may be very valuable in a major long term event.

Oxford Handbook of Emergency Medicine in General Practice. Lawrence.
Oxford University Press. 96. $30 good coverage of the basics of emergency
medicine in easy to read format.

Merck Manual Vol 1: General Medicine. Berkow. MSD. 93. $15 Good reference,
but can be complicated and verbose

Merck Manual Vol 2: Specialties. Berkow. MSD. 93. $15. Both volumes are
also available as a combined text, for about $25. The entire Merck Manual is
available for download from the "Virtual Hospital" site.

International Medical Guide for Ships. W.H.O. ISBN 9241542314

* Ships Captains Medical Guide. Her Majesty's Stationary Office. 1983 My
personal favourite. I would recommend this book to everyone. It covers the
management of most common problems in an excellent format, designed for ships
isolated at sea. Also good description of drugs and when to use them. The new
22nd edition is in press. The American equivelent is called "The Ships
Medicine Chest and Medical Care At Sea" and is published by the US office for
public health.

* Wilderness Medicine: Management of Wilderness and Environmental
Emergencies. Ed Auerbach $175. I recently bought this book, and can strongly
recommend it. Given its price I would suggest only those who already have a
good basic knowledge consider buying it.

* Book for Midwives : A Manual for Traditional Birth Attendants and
Midwives. Klein. Hesperian Foundation. ISBN 0942364228 Best book of its kind.
Safe childbirth in a low-tech environment with minimal backup.

Do-It-Yourself Medicine. Benson. Paladin Press 1996. ISBN 0873649184 $20.
I have not seen this book, but understand it is the up dated version of
Medicine Chest, and addresses some of that books problems. Recommended by
many.

* US Special Forces Medical Handbook. Paladin Press. 1987. Again a little
dated, but still an excellent book. Even the new edition is still not
completely up to date. But its strengths overcome this. Good coverage all
areas including surgery, dentistry and preventive medicine.

* Emergency War Surgery: US revision of Nato Handbook. G.P.O 1988 $50 ISBN
9999814328. The do-it-yourself surgery guide. Designed for junior doctors with
minimal trauma experience going into a war zone. Starting to be a little
dated, but the basics don't change.

Field Surgery Pocket Book. Her Majesty's Stationary Office. British
version of the above. I personally prefer this one to the NATO handbook, but
each are equally good.

6.1 What you stock up on should be related to what you know how to use and
what you can obtain. There are potentially thousands of drugs and different
pieces of medical equipment and you can't stock everything. Fortunately, it is
possible to manage 90% of medical problems with only a moderate amount of
basic equipment and drugs.

Obviously, sometimes the treatment may not be as such high quality as that
provided by a proper hospital, but it may be life saving and reduce long term
problems. For example, a broken tibia is usually managed by a general
anesthetic, an operation for an internal tibial nail, followed by pain relief
and physio. But it can be managed by manipulation with analgesia and
immobilization with an external splint for 6-8 weeks and as a result the
patient may be in pain for a few weeks and have a limp for life, but still
have a functioning leg. Also, appendicitis has been treated with high dose
antibiotics when surgery has been unavailable such as on a submarine or in the
Antarctic. Although in both cases management is sub-optimal and may have some
risk, in a survival situation it can be done and may be successful, with
limited medication and equipment.

6.2 Obtaining medications can be difficult. The problem is two-fold. First
is access and second is cost. Below are some suggestions for legally obtaining
medicines for use in a survival medicine situation.

* Talk to your doctor. Be honest explain exactly why and what you want,
that you want to be prepared for any disaster and have some important basic
meds available, for if medical care isn't freely available. Demonstrate an
understanding of what each drug is for and that you know how to safely use
it. Most MD's would probably be very supportive. Although, I would suggest
that you don't request narcotics the first time. Then return the meds when
they have expired, this will confirm that you are not using them
inappropriately.

* Discuss with your MD your plans for a trekking holiday. Most MDs
recognise the importance of an adequate medical kit if you are travelling in
the 3rd world or doing isolated backpacking. Most would prescribe
antibiotics, rehydration fluid, simple pain killers, anti- diarrhoea meds,
antibiotic and fungal creams, and if climbing steroids and frusemide for
AMS.

* Buy a boat. Australia, New Zealand and the UK, require all boats
sailing beyond coastal limits to carry a comprehensive medical kit. This
includes antibiotics, strong narcotic analgesia and a variety of other meds.
Although not a legal requirement in the US, I imagine most MD's would
happily equip an ocean going yacht with a comprehensive medical kit,
especially if you can demonstrate a basic medical knowledge. The US Public
Health service offers suggested medications and equipment, depending on
numbers and expected isolation.

* Prescription medicines are available over the counter in many third
world countries. I am unsure of the legalities of purchasing these. I
imagine a single course of antibiotics would be unlikely to be a problem,
but that large amounts or narcotics would be illegal.

* Not for human use. Veterinary meds are widely available and relatively
cheap. Several books discuss obtaining them (Benson's books, see book list),
so I won't cover it in detail here. I personally don't recommend this, but
obviously for some it is the only viable option. Generally speaking most
veterinary drugs come from the same batches and factories as the human
version, the only difference being in the labeling. This is the case for
most common single-component drugs such as antibiotics. If you are going to
purchase veterinary medications I strongly suggest only purchasing
antibiotics or topical preparations and with the following cautions:

Make sure you know exactly what drug you are buying, (1) avoid
preparations which contain combinations of drugs and also obscure drugs for
which you can find no identical human preparation and (2) avoid drug
preparations for specific animal conditions for which there is no human
equivalent. Buy drugs which are generically identical to their human
counterparts, e.g. Amoxycillin 500mg (Vet) = Amoxycillin 500mg (Human), etc.

* Obtaining general medical supplies is often easier. Basic bandages and
stethoscopes, etc. can be bought from any medical supply house. I understand
there is no federal law prohibiting the purchase of things like sutures,
syringes, needles, IV's etc., but some states can make it difficult. Try
looking in the yellow pages for medical or emergency medical supply houses
or veterinary supplies. A number of commercial survival outfitters offer
first aid and medical supplies, however I would shop around before
purchasing from these as their prices, in my experience, are higher than
standard medical suppliers. The above approaches for obtaining medicines can
also be used for obtaining medical equipment if you do have problems. The
most important point is to be able to demonstrate an understanding of how to
use what you are requesting.

6.3 I've included three kits. The first is
designed for someone with some limited medical knowledge and a good book. A
lot of common problems can be managed with it, minor trauma (cuts and minor
fractures), simple infections and medical problems. The
second is designed for someone with extensive medical training and should
be able to cope with 90% of common medical problems, including some surgery,
spinal and regional anesthesia, general anesthesia with ketamine, treating
most common infections and medical problems, and moderate trauma. Obviously
there is a vast middle ground between the two. The kits are designed for
long-term care rather than to cover short (48 hrs) delays in getting to formal
medical care. The third is a reprint of the medical
scales for British flagged commercial vessels, to give you an idea of what the
"experts" believe is required for isolated intermediate term survival
medicine.

NOTE:

1) I've tried to use the international generic names for drugs. However,
there are some differences between the British and the US pharmacopoeias and
where possible I've tried to include both e.g. Lignocaine (UK & NZ) =
Lidocaine (US)

2) I have not included any quantities. This is dependent on what you are
planning for and what you can afford. Unfortunately most medications require
rotation, with 1-5 year shelf lives, making this a costly exercise, as they
are not like food you can rotate into the kitchen

Your choice of suture material is up to you. Vicryl is a synthetic
dissolvable one, but takes up to 4-6 weeks to dissolve, so I think it is
the ideal survival thread. But a variety of non-dissolvable sutures are
available which will last forever.

5ml syringes

20g needles

Oil of cloves (tooth ache)

Emergency dental kit (commercial preparation)

A smaller kit for your bug-out bag could be made up from the above. Include
some combined dressings, a couple of bandages, bandaids, tape, some Tylenol,
Benadryl and some loperamide.

This list may seem extreme, but is designed for a well trained person in
a worst case scenario. Even though it is a long list, it all packs down,
mine which has a similar content packs into two medium size nylon
multi-compartment bags and a Plano rigid 747 box. I haven't included
descriptions of what specific items are, on the assumption that if you don't
know what it is, you shouldn't have it or try to use it.

General

Large gauze dressings

Sm gauze squares

Combat dressings

Petroleum gauze

Plastic bags

Bandaids - assorted sizes and shapes

Elastoplast dressing

Steristrips - assorted sizes

Tincture of Benzoin

Roller (elasticated + cotton) bandages (2in/4in/6in)

Triangular bandages

Safety pins

Cotton buds

Paper tape (1/2 in/1in)

Sleek tape (1/2in/1in)

Oropharyngeal airways

Resuscitation face mask with one way valve

BP cuff

Stethoscope

Otoscope

Sm Torch (flash light)

Thermometer (rectal for children)

Heavy duty scissors

Space blanket

Air splints (arm/long-leg/short-leg)

SAM splints

Plaster of Paris (or fibreglass) roller bandages (4in/6in)

Multidip urine test strips

Pregnancy test kits

Sterile and unsterile latex gloves

Scrub Suits

Fluroscene eye strips

Eye patches

Sm eye magnet (for FB's)

Snake bite kit (for those of you unlucky enough to have them :-))

The Sayer suction kit is recommended. It is slightly more expensive,
but I understand more effective in removing venom. I refer you here to
the excellent rec.backcountry FAQ on Snake Bites

British medical scales for ocean going ships, from the Marine safety
agency, Merchant Shipping Notice No.M.1607. It is compatible with the
medical treatments described in the Ship's Captain Medical Guide, the new
edition (22nd) of which will be published shortly. The amounts suggested are
per 10 people.

This section contains a significant amount of technical information. It is
intended as a very brief overview and introduction of the subject area. I accept
no responsibility for the accuracy or otherwise of this material. A suggested
books section gives more specific references for these topics:

7.1 Storage and Rotation of Medications

Medications can be one of the more expensive items in your storage inventory
and there can be a reluctance to rotate them due to this cost issue and also due
to difficulties in obtaining new stock.

Unfortunately, drugs do have limited shelf life. It is a requirement for
medications sold in the US (and most other first world countries) to display an
expiration date. It is my experience that these are usually very easy to follow,
without the confusing codes sometimes found on food products, e.g. -- Exp.
12/00=December 2000.

I cannot endorse using medications which have expired. But having said that
it is my understanding that the majority of medications are safe for at least 12
months following their expiration date. A colleague recently did some aid work
in the Solomon islands and a local pharmaceutical warehouse gave him a number of
expired drugs. They stated that the drugs were safe to use for at least another
18 months. As with food the main problem with expired medicines is not that they
become dangerous, but that they lose potency over time, and the manufacturer
will no longer guarantee the dose/response effects of the drug. The important
exception to this rule is the tetracycline group of antibiotics, which can
become toxic with time, there may be others that I am unaware of but it is very
difficult to obtain this information. Let the buyer beware, the expiry dates are
there for a reason.

In addition, I recommend that if you are acquiring medications on a doctor's
prescription that when you have the prescription filled you explain the
medications are for storage (you don't need to say exactly what for), and
request recently manufactured stock with distant expiration dates.

The ideal storage conditions for most medications is in a cool, dark, dry
environment. These conditions will optimise the shelf life of the drugs. A small
number of drugs require refrigeration to avoid loss of potency. These include
insulin, ergometrine, oxytocin and some muscle relaxants. Others such as
Diazepam rapidly lose potency if exposed to the light.

7.2 Antibiotics

7.2.1 Antibiotic Recommendations

In some cases access to antibiotics may be very limited. The following is my
preferred list of antibiotics. If your limited in what you can get, I suggest
you purchase and expand in this order. All are good broad spectrum antibiotics
and have different strengths and weakness. I suggest you purchase an antibiotic
guide, most medical book shops have small pocket guides for junior doctors
detailing which drug to use for which bug and outlining sensitivities.

1st A Broad spectrum Penicillin (e.g.-- Amoxycillin +Clavulanic Acid)

2nd A Quinolone (e.g.-- Ciprofloxacin)

3rd A Cephalosporin (e.g.-- Cefaclor)

If allergic to Penicillin, I would advise A Quinolone as a first choice with
some Metronidazole as a anerobe back-up. Alternative would be Erythromycin.

7.2.2 Antibiotic Summary

The Bugs:

A basic understanding of how bugs (read bacteria) cause infections is
required to appropriately use antibiotics. I will not discuss viral or other
infective agents here. This is not the forum for a proper discussion, so
consider this a brief introduction. There are HUNDREDS of bacteria, I will only
discuss common disease causing ones in man.

Four Classes of Bacteria

- Gram positive ( + ve )

- Gram negative ( - ve )

- Anaerobes

- Others

Gram positive bacteria stain blue and gram negative bacteria stain pink, when
subjected to a gram staining test. It is related to the presence or absence of a
coating in the cell wall of the bacteria. Anaerobic bacteria are ones which
require no oxygen to grow. Bacteria are also described by their shape (cocci =
round, bacilli = oval) and how they are grouped together (chains, clusters,
pairs)

Gram Positive Bacteria ( Gram +ve)

- Staphylococcus: Commonest pathogen is S. aureus. Gram + cocci in clumps.
Causes boils, abscesses, impetigo, wound infections, bone infections,
pneumonia (uncommonly), food poisoning and septicaemia. Generally very
sensitive to Flucloxacillin as first choice and Augmentin and the
Cephalosporins. A strain which is resistant to the above, known as MRSA and is
currently treated with vancomycin.

- Neisseria meningitidis: Gram -ve cocci in pairs. Common cause of
bacterial meningitis, may also cause pneumonia and septicaemia. Can be rapidly
fatal. Sensitive to penicillins, cephalosporins, quinolones, cotrimoxazole and
tetracyclines.

- Chlamydia sp: Includes C.pneumonia, responsible for a type of atypical
pneumonia and C.trachomatis, responsible for the sexually transmitted disease
chlamydia. It is best treated with Tetracyclines or as second choice a
macrolide.

- Mycoplasma pneumoniae: A cause of atypical pneumonia. Treated best with
a Macrolide, with a second choice of a tetracycline.

The Drugs:

Penicillins - These act by preventing replicating bacteria from producing a
cell wall. A number of bacteria produce a enzyme which inactivates the
penicillins ( B-lactamase).

*Phenoxymethylpenicillin (Penicillin V): Oral preparation of above.
Usually used only for the treatment of sore throats (strep throats), in other
infections largely replaced by amoxycillin which is better absorbed.

*Flucloxacillin: Oral and IV drug of choice for Staph infection such as
cellulitis, boils and abscess and bone infections. Also usually effective
against Strep, but not first choice.

*Amoxycillin: (newer version of ampicillin): Oral and IV. Effective
against most gram positive and negative bugs. Limited use secondary to B-lactamase
resistance in many bugs. This is overcome with the addition of Clavulanic Acid
( eg Augmentin). Overcoming this resistance, makes this combination my ideal
survival antibiotic, with good gram positive, negative and anaerobic cover.
This drug I feel is the best "broad spectrum" antibiotic commonly available,
other AB's may be better for specific infections but this is the best all
purpose one.

Cephalosporins - Same method of action as penicillins. Developed in three
generations (now four, but not widely available). The third generation e.g.,
Cefotaxime (Claforan, IV only) and Ceftriaxone (Rocephin, IV only) have the most
broad spectrum. They are effective against most gram positives and negatives and
some variable anaerobic cover. The second generation e.g., Cefuroxime (Zinacef,
oral and IV) and Cefaclor (Ceclor, oral only) also have good general cover, but
are not as effective against some gram negative bacilli. This loss of gram
negative cover expands to most gram -ve cocci and bacilli in the first
generation cephalosporins e.g., Cephalexin (Keflex, oral only) and Cephazolin (Kefzol,
IV only). The third generation is ideal for use in those with very severe
generalised infection, meningitis or intra-abdominal sepsis (e.g., penetrating
abdo wound or appendicitis, with metronidazole added in) and the second
generation offer a good broad spectrum antibiotic for general use in skin,
wound, urinary and chest infections.

Quinolones - Acts by inhibiting DNA replication in the nucleus of the
replicating bacteria. New generation of antibiotics. Most common is
Ciprofloxacin. Very broad spectrum cover, except anaerobes. Excellent survival
AB, but my second choice due to amoxycillin + clavulanic acids better cover of
anaerobes. Effective for most types of infections except intra-abdominal sepsis
and gangrene.

Macrolides - Acts by inhibiting protein synthesis in the replicating
bacteria. Includes Erythromycin and the newer Roxithromycin and Clarithromycin.
Often used in people with a penicillin allergy, however it does have a reduced
spectrum (esp. with Gram negatives), but is an alternative to tetracycline in
Chlamydia. First choice in atypical pneumonias e.g., with Mycoplasma pneumonia.

Co-Trimoxazole - Acts by interfering with folate metabolism in the
replicating bacteria. Previously a very broad spectrum antibiotic, now has a
much more variable response rate due to resistance. Still useful for urinary
and, mild chest infections.

Metronidazole - Acts by directly damaging the structure of the DNA of the
bacteria/protozoa. Drug of choice for anaerobic infection. Should be used with
another broad spectrum AB in any one with possible faecal contamination of a
wound or intra-abdominal sepsis (such as severe appendicitis). Also the drug of
choice for parasitic infections such as Giardia.

Others - There are many other antibiotics available. I have only discussed
the common ones above. For further information I refer you to any Antibiotic
guide, of which there are many.

NOTES

In pregnancy Penicillins and Cephalosporins are safe. Many others are not (or
only during certain parts of the pregnancy). You should always check if any drug
you are using is safe, before using in pregnancy and breast feeding. The PDR
will tell you. If you want a specific reference try "Drugs in Pregnancy", Ed D.F
Hawkins.

This section contains a significant amount of technical information. It is
intended as a very brief overview and introduction of the subject area. I accept
no responsibility for the accuracy or otherwise of this material. A suggested
books section gives more specific references for these topics:

8.1 The basics of a diagnosis can generally be reached by a careful history
and physical examination. Modern medicine relies heavily on laboratory
investigations. In a survival situation these will not be available. However
there are some simple laboratory tests which can be performed with very little
equipment or chemicals. The problem is that even basic tests require some
equipment. Ranging from simple test strips to a microscope and a few chemicals.
Obviously what you are preparing for will dictate what tests you may want to be
able to perform.

8.2 Urine Testing: Urine is easily tested with multi-function dip stix. These
can test for the presence of protein, glucose, ketones, nitrates, red blood
cells and white blood cells. The test strip is dipped in a specimen of clean
catch urine ( i.e. you start to pee in the toilet, stop, then start again into
the specimen container, stop, and continue into the toilet) and panels
containing the test reagents change colour depending on the presence and
concentrations of the substance being tested for The colour changes are compared
to a table supplied with the strips. Can be used to diagnose urinary infections,
toxaemia in pregnancy, dehydration, diabetes (outside pregnancy) and renal
stones/colic.

The following is a quote on analysing urine from a book to be published on
the practice of medicine under relatively primitive conditions.

From . Roberts, S. D.; A Guide to the Practice of Medicine Under Austere
Conditions (Revised Ed.), 1997, to be published.

Urinalysis

Of the various bodily fluids, urine is the most easily obtained. It is
possible to perform a number of tests on urine with little or no equipment.
Visual and olfactory examination of a urine sample alone can provide
considerable information. Urine which is pink, red, or red-orange may contain
blood, although it is important to remember that these colors may also be seen
in those who have eaten certain foods, such as beets, blackberries, or rhubarb.
Urine which is green or blue- green, or which takes on these hues on standing,
may indicate diseases of the liver or gall bladder. Bright yellow or
yellow-orange urine is indicative of kidney dysfunction (if there is no reason
for the urine to be concentrated and if the color is maintained for several
days). Cloudy urine may result from abnormally high levels of phosphates or
carbonates in the urine, and may be a precursor of kidney stones. Cloudy urine
may also indicate the presence of an infection, particularly if the fresh urine
has an odor of ammonia or other disagreeable odor (note that urine will develop
an ammoniacal odor on standing).

It is possible to approximately localize an infection that is producing
cloudy urine by using the three glass test. This test requires three clean
containers (glasses), of which at least one (the second used) will need a
capacity of at least 500 ml. In this test, the first 5 ml is voided into the
first container, the second container is used until the patient is almost done,
and then the third container is used to collect the last 5 ml. If the urine in
the first container is the most cloudy, with decreasing cloudiness in the
remaining containers, a urethral infection is the most likely cause. If the
urine in the first container is less cloudy than either of the following two, a
kidney, bladder, or prostate infection is indicated as the cause, while, if the
urine in the third container is the cloudiest, the prostate is the likely site
of the infection.

The odor of maple syrup associated with fresh urine is, of course, the
classic sign of maple syrup urine disease. The urine may also have
characteristic odors which are associated with other genetic disorders: the
"mousy" odor associated with phenylketonuria, for instance. The presence of
glucose in urine has long been recognized as an indication of diabetes, and its
detection has been assigned a high degree of importance by the general public.
While its presence was at one time detected by taste, a more aesthetically
acceptable method (which is also less likely to transmit infection) is to heat
the urine and observe the odor. If the scent of burning sugar or caramel is
detected, there is an excessive amount of sugar present.

Proteins, or carbonates and phosphates, in urine may be detected by filling a
test tube three- fourths full of urine and boiling the upper portion. Any
cloudiness produced by this may arise from either the presence of carbonates and
phosphates (which may be normal) or from the presence of proteins. These two
causes may be differentiated by adding a small amount of acetic acid (3-5 drops
of 10% acetic acid) to the tube: if the cloudiness vanishes, carbonates and
phosphates were the cause; if the cloudiness persists (or becomes apparent only
after the acid is added), proteins are present.

The iodine ring test is a simple test which can detect the presence of bile
in the urine before color changes or jaundice make its' presence obvious. In
this test, the appearance of a green ring after layering a 10% alcoholic iodine
solution over the urine in a test tube indicates the presence of bile.

8.3 Blood Counts: There is no easy way to do blood counts without some basic
equipment. You require a microscope and a graded slide. A graded slide is a
microscope slide which has very small squares etched onto its surface. Using a
standardised technique a smear of blood is placed on the slide. Now using the
microscope the number of different types of blood cells in a square on the slide
is counted, this is then repeated several times and then averaged. This
technique will give you:

- White Cell count

- White Cell differential

- Red Cell count

- Platelet count

8.4 Blood Grouping: The simplest thing to do is have your group or expedition
blood typed prior to your expedition or TEOTWAWKI. However provided you have
several basic chemicals a cross match is a simple test. But due to its potential
fatal complications if done incorrectly I will not describe the procedure here.
It is well described in any basic laboratory medicine textbook. Also see
'Lucifer's Hammer" quote in section 12.0.

8.5 Pregnancy Tests: The ability to accurately diagnose pregnancy may be
important, both for psychological reasons and for the practical reasons.
Currently available pregnancy test kits test urine for the presence of the
hormone Human chorionic gonadothrophin (HCG). They require only a small amount
of urine, and are accurate from 10-14 days from conception.

8.6 Blood Glucose test strips: Also known as BM stix, after a common brand.
This can be used to diagnose diabetes (in a survival situation), both generally
and during pregnancy, also it can detect low or high blood sugars in other
severe illnesses. A finger or toe is pricked and a drop of capillary blood is
collected onto a test strip. It's allowed to sit for 30 seconds, then is wiped
off, and a further 90 seconds, then the colour of the test strip is compared to
a control chart to give a blood glucose level.

8.7 Gram Staining: This is a technique for approximate identification of
bacteria in urine, pus, sputum, cerebral spinal fluid (csf) and from bacterial
cultures. Although not highly accurate in species identification, combined with
a knowledge of the clinical situation, it enables a good guess to be made for
the appropriate antibiotic. It requires a microscope and also several chemical
solutions. This is a very standard microbiological procedure and can be learned
very easily at any entry level microbiology course.

The basic technique is:

(1) the infected area or fluid is swabbed and the swab smeared onto a slide
and dried and fixed.

(2) It is then washed with crystal violet for 1 min, rinsed, washed grams
iodine for 1 min, long rinse, washed safranin 30 seconds, washed again then
dried. It is then examined down the microscope. The bacteria will stain certain
colours and appear certain shapes depending on species, this aids in
identification as discussed already.

The standard technique of giving fluids to an unconscious, shocked or
dehydrated person is with intravenous fluids. However this may not be possible
in a survival situation. An alternative is to give fluids rectally. This
method will obviously not work if the cause of the problem is severe diarrhoea.
This is included for interest only and I do not recommend this procedure :-)

The person is placed on their side, with the buttocks raised on two
pillows. A lubricated plastic tube with a blunt end (a large urinary catheter
or nasogastric tube is ideal) should be passed through the anus into the
rectum for about 9 inches. It should pass with minimal pressure and should not
be forced. The danger is perforating the bowel.

The tube should be taped to the skin. A longer length of tubing and a drip
bag or funnel should be attached to the end and elevated. Then 200mls of fluid
slowly dripped in over 15 to 20 minutes. The catheter should then be clamped.
This can be repeated every 4 hours with a further 200mls. Upto
1000-1200mls/24hrs can be administered this way. If 200mls is tolerated it can
be worth increasing the volume slightly or reducing the time to 3 1/2 or 3
hrs. If there is over flow the volume should be reduced. A rectum full of
faeces does not absorb water very well, so the amounts may need to be reduced,
but given more frequently.

9.2 * Death

People are going to die, one way or another it will happen and you need to
be prepared for it.

9.2.1 Diagnosing Death:

No pulse

No respirations

No heart sounds

No pupil response to light

Hypothermia Note:

Precautions need to be taken where the person concerned has been in the
extreme cold, either the snow or very cold water. Severe hypothermia causes
a profound slowing in the bodies metabolism and as a consequence can mimic
death. Hence the saying " You're not dead, until your warm and dead."

One option is to aggressively resuscitate anyone found in the above
situations, although in my view this is likely to be an extremely uphill
battle in a survival situation, especially if they clinically appear to be
dead. The management of severe hypothermia is dealt with in detail in most
advanced first aid texts. But for interest the basics are included below:

Extreme care needs to be taken in handling a very hypothermic patient as
they are predisposed to developing ventricular fibrillation if roughly
handled. But the goal is slow rewarming

- body heat

- warm room

- space blanket

- warm IV fluids *

- irrigation of stomach and bladder with warm fluid *

- packing groin and axilla with hot packs. *

* there is still some debate in the literature about the place for these
last 3 options.

9.2.2 Handling a dead person:

The human body decomposes very quickly, especially in hot weather. A
decomposing body rapidly becomes a health hazard. A dead person should be
buried quickly, in a reasonably deep grave to avoid predation by scavengers.
Most religions have short rites for the burying of the dead, but for the
non-religious a favorite poem may be appropriate.

9.2.3 Records:

It is important to document the fact that someone has died, but also the
circumstances of the death, your guess as to a cause of death and how the
body was disposed of. This becomes important for legal reasons should things
return to normal or in the case of an isolated expedition for the coroner on
your return.

9.3 * Gastroenteritis and Dehydration

Gastroenteritis is still a killer in the third world especially for young
children (I include typhoid, cholera, giardia, salmonella, "food poisoning"
etc, under the general heading gastroenteritis). The most important preventive
action you can take in preventing gastroenteritis is to wash your hands
following defecation. Also hands should be washed before handling food,
dealing with the sick or babies and infants. All drinking water should be
boiled unless you are sure of its purity. Hand washing and clean water will
prevent 99% of diarrhoeal disease. This topic is very well covered in "Where
there is no Doctor".

9.3.1 What kills is not having diarrhoea or vomiting, but dehydration.

Again this is not the forum for detailed medical treatments. But you
must understand how to recognise dehydration and know how to treat it. The
basis of any treatment is replacement of lost fluids and electrolytes. This
is a relatively simple matter if you have access to IV fluids, but without
you must rely on the patient drinking. It is often difficult to get a
patient to drink, especially when they feel very unwell, but it must be
emphasised to them that if they don't drink they will die. The secret is
small amounts of fluid, frequently. If you try and force a large glass down,
it will come straight up right away. They must put in at least what they are
putting out, more in hot weather. There has been much debate over what to
offer to replace lost fluids and electrolytes. It must contain not only
water, but also Sodium (table salt), Potassium (light salt) and also some
form of sugar. The sugar is vital for absorption to take place in the
intestines, salts alone are poorly absorbed when the gut lining is damaged
as it often is in gastroenteritis. I refer you to an excellent article in
*Scientific American* May 1991 on oral rehydration formulas (thanks to Logan
VanLeigh for the reference).

9.3.2 Oral Rehydration Fluid:

The following is an easy formulae for making an oral rehydration fluid.

I've tried to emphasise the importance of basic hygiene in any survival
situation. This is especially true when performing any surgical procedure.
From suturing a small cut or dressing a wound, to dealing with a major injury
or operation.

You should wash your hands for 2-3 minutes with soap or a surgical scrub
and then if available use a pair of sterile gloves. The instruments you are
working with should also have been sterilised.

There are several effective low tech ways to do this:

1) Soaking in Alcohol: Soak the instruments in Ethyl Alcohol. The higher
the concentration and the longer the soak the better. Recommended that > 70%
(ideal is >95%) solution for >12 hrs. This time can be shortened to several
hours by the addition of Formaldehyde solution to the Alcohol.

2) Boiling in water: Boil in water for 30 minutes (at sea level). Will
cause rusting of anything which holds a edge such as scissors and knives.
Deionised or soft water will reduce this problem.

3) Pressure cooking: The gold standard in a survival situation. This is
the basis for hospital autoclaves. Ideally the instruments must be cooked
for 30-40 minutes at temperatures >110 deg Celsius at 18-20 psi. Using this
method it is possible to sterilise instruments wrapped in cloth or linen.
This will mean they stay sterile following removal from the pressure cooker
and can be used at a later date. If packed allow further 15-20 minutes
drying time. The instruments need to be placed on a rack in the pressure
cooker, above the water in the bottom, rather than in the water. The main
problem is that home pressure cookers and canners mostly they come in a
range of 5, 10 and 15 lbs of pressure which I understand equates to 220, 230
and 240 degrees Fahrenheit at sea level pressure. There's no safe way to
take them up to 20 psi without the serious risk of blowing their pressure
safety valves. They generally come in two types, the dial gauge and the dead
weigh pressure gauge. The dial gauge can do odd pressure levels, but really
needs to be calibrated periodically with a year being the suggested
interval. This calibration is usually beyond what the average homeowner can
do, thus they are not well suited to survivalist use. The dead weight gauge
can only do what it is manufactured for, 5, 10, 15 psi for most pressure
canners and usually only 10 or 15 psi for most pressure cookers. The best
advise to those using these devices is to use one set for 10 or 15 psi and
lengthen the "cooking time" by 15 minutes. There is no good information
available about improvising "autoclaving", so this information must be used
with caution. (Thanks to Alan Hagan for help with this section )

10.1 Finally, I feel I should make a passing comment on alternative
therapies. I *EXCLUDE* herbal- and plant-based medicines from the following
comments, because obviously these medicines form the basis of modern
pharmacology and post-TEOTWAWKI will do so again. I stress these are my
opinions. If you find a particular alternative treatment works, and wish to
practice it and use it post-TEOTWAWKI then that's fine. However I think it
would be unsafe to ignore conventional medicine. The alternative therapies are
most commonly used and successful with low grade chronic problems. I would
suggest that what will kill you and what you need to prepare for is not
chronic lower back pain or irritable bowel syndrome, but major trauma, or
cholera, or severe pneumonia and I don't think arnica or a good foot rub will
fix the problem. Things which are currently annoying or distressing chronic
problems may pale into insignificance alongside finding enough to eat and
drink and avoiding the baddies. (But who knows, under survival stress it may
make them worse :-))

10.2 Colloidal Silver should be specifically mentioned as it receives a
lot of questions on the news group. IMHO its merits have been exaggerated in
the extreme. There is no reputable scientific evidence that it has any useful
in-vivo (in the human body, rather than in a lab) antibiotic or antibacterial
effects. If its proponents can supply recent case/controlled trials, published
in a reputable scientific or medical journal, I am prepared to revise my
opinion and include the results here. I just advise caution to those who plan
to rely on CS as their antibiotic in a survival situation.

There are hundreds of little sayings within medicine about dozens of topics.
At first some of them sound extremely basic or stupid, but the all have a basis
in fact. Medicine is made up of common sense. Here's a selection. I welcome
additions.

* Knowledge is power.

* First do no harm.

* Masterful inactivity saves lives.

* The placebo effect has cured more people than any doctor.

* If it hurts rest it or immobilise it.

* Always wash your hands before touching a patient.

* Its better to boil all your water, than die of diarrhoea.

* Don't shit in the water you are going to drink (or let anyone else).

* A comfortable, warm bed fixes many problems, a good meal fixes many
more.

* Direct pressure stops bleeding.

* Pretend you know what you are doing and people will believe you do.

* Don't stitch a dirty wound.

* Clean boiled water is a great antiseptic (So is urine but we won't start
that one)

I've included these quotes because one accurately describes a primitive
medical technique, giving an example of how a life saving procedure such as
cross matching blood can be done under primitive conditions and the second and
third summarises several key realities of a long term TEOTWAWKI situation.
Obviously I do not recommend using this procedure.

When Maureen reached the hospital, Leonilla Malik took her and led her firmly
into a front room.

"I came to help, "Maureen said, "But I wanted to talk to the wounded. One of
the Tallifsen Boys was in my group and he-". "He's dead.", Leonilla said. There
was no emotion in her voice. "I could use some help. Did you ever use a
microscope?" "Not since college biology class" "You don't forget how" Leonilla
said. "First I want a blood sample. Please sit down here." She took a hypodermic
needle from a pressure cooker. "My autoclave" she said. "Not very pretty but it
works." Maureen had wondered what had happened to the pressure cookers from the
ranch house. She winced as the needle went into her arm. It was dull. Leonilla
drew out the blood sample and carefully squirted it into a test tube which had
come from a child's chemistry set. The tube went into a sock: a piece of
parachute cord was attached to the sock, and Leonilla used that to whirl the
test tube around and around her head. "Centrifuging" she said. "I show you how
to do this and then you can do some of the work. We need more help here in the
lab". She continued to swing the test tube. "There", she said. "We have
separated the cells from the fluid. Now we draw off the fluid and wash the cells
with saline." She worked rapidly. "Here on the shelf we have cells and fluid
from the patients who need blood. I will test yours against theirs." "Don't you
want to know my blood type?", Maureen asked. "Yes. In a moment. But I must make
the tests anyway. I do not know the patients blood types and I have no way to
find out, and this is more certain. It is merely very inconvenient."

The room had been an office. The walls had been painted not long ago and were
well scrubbed. The office table where Leonilla worked was formica, and very
clean. "Now", Leonilla said, "I put samples of your cells into a sample of the
patient's serum, and the patient's cells in yours, so, and we look in the
microscope."

The microscope had also come from a child's collection. Someone had burned
the local high school before Hardy had thought to send an expedition for its
science equipment. "This is very difficult to work with.", Leonilla said, "But
it will work. You must be careful with the focus." She peered into the
microscope. "Ah, Rouleaux cells. You cannot be a donor for this patient. Look so
that you will know."

Maureen looked in the microscope. At first she saw nothing, but she worked
the focus, the feel of it coming back to her fingers. Leonilla was right, she
thought. You don't really forget how. She remembered that you weren't supposed
to close the other eye, but she did anyway. When the instrument was properly
focused she saw blood cells. "You mean the little stacks like poker chips?", she
asked.

"Poker chips?"

"Like saucers-"

"Yes. Those are Rouleaux formations. They indicate clumping. Now what is your
blood type?"

"A" Maureen said.

"Good. I will mark that down. We must use these file cards one for every
person. I note on your card that your blood clumps that of Jacob Vinge, and note
the same on his card. Now we try yours with others." She went through the same
procedure again, and once more. "Ah. You can be a donor for Bill Darden. I will
note that on your card and his."

"No, we must learn to live without penicillin." She grimaced. "Which means a
simple cut untreated can be a death sentence. People must be made to understand
that. We cannot ignore hygiene and first aid. Wash all cuts."

12.2 For a fictional account I recommend James Wesley Rawles "TEOTWAWKI".
This contains accounts of survival medicine in practice (in addition much other
excellent material) with detailed descriptions of several surgical procedures
and childbirth in a post-collapse society. Although there is some dramatisation
to it I feel this accurately reflects some of the medical situations which will
need to be faced.

12.3 These are some final thoughts about the medical situation post a severe
TEOTWAWKI. I've included this just to stimulate some thoughts and discussions:

With no antibiotics there would be no treatment for bacterial infections,
pneumonia and a cut would kill again, contagious diseases (including those
sexually transmitted) would make a come back and high mortality rates would be
associated with any surgery. Poor hygiene and disrupted water supplies would
lead to an increase in diseases such as typhoid and cholera. Without vaccines
there would be a progressive return in infectious diseases such as polio,
tetanus, whooping cough, diphtheria, mumps, etc, especially among children.
People suffering from chronic illnesses such as asthma, diabetes or epilepsy
would be severely effected with many dying (especially insulin dependent
diabetics). There would be no anesthetic agents resulting in a return to
tortuous surgical procedures with the patient awake or if they were lucky drunk
or stoned. The same would apply to painkillers, a broken leg would be agony and
dying of cancer would be distressing for the patient and their family. Without
reliable oral contraceptives or condoms the pregnancy rate would rise and with
it the maternal and neonatal death rates, woman would die during pregnancy and
delivery again and premature babies would die. Women would still seek abortions
and without proper instruments or antibiotics, death from septic abortion would
be common again. In the absence of proper dental care teeth would rot and
painful extractions would have to be performed. What limited medical supplies
were available would have to be recycled, resulting in increases risks of
hepatitis and HIV infection.

THE MOST IMPORTANT THING TO REMEMBER IS THAT GOOD HYGIENE CAN PREVENT MANY
PROBLEMS.

WASH YOUR HANDS AND BOIL YOUR WATER!

Any comments or suggestions welcomed. I plan to periodically update this FAQ
with any recurring questions from misc.survivalism and also